The Qualified Independent Contractor (QIC) for the second level of appeals (C2C Solutions, Inc.) began a new telephone demonstration in January 2016. The demonstration is initially being tested with appeals originating from Jurisdictions C and D for oxygen and diabetic supplies. This project allows invited suppliers to speak with a reconsideration processor via a telephone conference to try and resolve up to five open cases favorably. If it is determined during the conference that a document is missing, then an opportunity will be provided to cure the deficiency before the case is closed. The intended result is to fully resolve the appeal and prevent claims from escalating unnecessarily to the third level of appeals. For DME suppliers, the potential ripple effect of this demonstration is monumental!

Since we transitioned to the QIC in 2004, the first opportunity suppliers have to discuss the details of a formal appeal happens in the third level of appeals (at the ALJ level). And, with the significant ALJ backlog, suppliers have been waiting years to get their voices heard on a single claim.

Interestingly, for suppliers that take advantage of the telephone appeal opportunity, C2C will further consider reopening claims similar to those reviewed in the demo. The data for reopening escalations will come from decisions dating back to 01/01/2013 to current. This will include appeals that may be currently processing with the QIC, and those that were previously adjudicated after 01/01/2013. Appeals caught in the backlog of the ALJ docket will also be eligible for reopening and, absent a favorable decision, these ALJ appeals will not lose their standing on the docket.

While the program is voluntary, the QIC does have to initiate the initial invitation to participate in the telephone demonstration. When the QIC selects an eligible appeal for the demo, the supplier will be contacted by mail with a letter and a response form. The supplier must respond within 14 days to lock in the time and date of the formal call. If the suggested date and time is unworkable, suppliers may submit a request to reschedule via mail or fax, and requests will be granted at the discretion of the QIC.

The additional complexity associated with conducting telephone appeals will extend the timeframe for a decision on these demonstration appeals from 60 days to 120 days. Additionally, by opting to participate the supplier cannot “escalate” their appeal to the ALJ and bypass the second level of appeal. The supplier can, however, appeal to the ALJ if the C2C renders an unfavorable decision, even if it is rendered as a result of a demo conference.

Overall, this demo gives suppliers a voice earlier in the appeals process and should produce favorable results by reducing cases that have to escalate to ALJ. It also has the opportunity to free up some backlogged cash flow by replicating results to similar claims through a unique reopening process.

We will be engaging in discussions to free up cash flow held up by audits in our April 12th event “Leverage Your Error Rate To Reduce Audits” Check out the details and join us for this event!